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Myra's case is just one instance of many that a mental health nurse encounters on a regular schedule.
Nursing is best practiced when it follows the intentions of its founder Florence Nightingale who urged that nursing should be a practice that should literally provide for and care for the patient. Nursing, in other words, should be purely patient-centered. This caring extends to all aspects not just to the illness so that one treats the patient in a holistic way, considering all components of the patient such as the family, his or her social needs, hobbies, desires, spiritual inclinations and so forth. When done in this way, nursing extends itself from an automatic, robotic procedure to something that can motivate the nurse and uplift the patient (Watson, 1998). 'Nursing', in other words, extends to caring for the patient as a whole.
An effective nurse will strive to accomplish her best in the four metaparadigms that are essential (according to Fawcett) to the field of nursing: These are health / environment/person/and nursing. Health refers to the generalized condition as relevant to that particular individual (in this case, Mayra); environment is holistic including social and cultural dynamics (i.e. The patient's family and friends as well as community); 'person' refers to the sick individual as a person rather than a 'patient' (the nurse has to have dignity and respect for the patient); and 'nursing' refers to the root of nursing i.e. caring rather than as a mechanized set of practices. This is the crux and the importance of a therapeutic relationship.
Nursing (as, for instance, see Watson, 1988) is far more than simply providing the patient with the necessary treatments. It includes caring for the person as a whole, namely seeing that all his, or her, needs are met. The person is a part of a whole and this includes taking care of the environment and ensuring that the person receives support as well as that his cultural and emotional needs is met. The patient, too, should be regarded as a person rather than as a 'patient' per se.
Placing herself within the patient's locus of concern, the nurse will firstly see that communication is conducted along the following lines: she will speak slowly and use short, simple words and phrases. She would consistently identify herself, and address the client by name at each meeting; she will focus on one piece of information at a time; and she would review medical plans and procedures with the patient until she has affirmed that the patient has understood and agrees. With someone with dementia, this may take repetitious attempts and may be frustrating (Norberg, 2012).
In fact, patients with dementia are often frustrated by their incapacity and by their living in a confusing, unfamiliar world that has suddenly become overwhelming to them (Norberg, 2012). As reaction, they may become aggressive. In this case, the nurse is advised to shift the topic to a safer, more familiar one. She is advised to respond calmly at all times and not raise her voice whilst seeking to identify stressors that increase agitation and helping patients such as Myra respond to them. The nurse cans also her patient with techniques to deal with stressors in a calm way. (WebMD)
Patients like Myra who has dementia have to be protected from falling. In fact, falls are a major problem amongst the elderly, particularly amongst the 65+ population and can lead to many related problems, and occasionally to fatal results. Approximately, a third to one-half of elderly individuals fall each year (Downton, 1991), whilst in the United States, alone, one in three people, who are over 65, fall at least once a year, and this incidence increases to one into two people for those who are over 80 (Todd & Skelton, 2004; McClure et al. 2005). The severity of fall complications also increases over age, particularly with females, resulting in more mortality and morbidity related to fall with individuals whose age exceeds 70 than with those who are younger (Rubenstein & Josephson, 2006). The nurse caring for an elderly patient, such as Myra, and particularly with someone who has dementia can protect falls by ascertaining that the patient's environment is well lit and free of possible objects that may make her fall. Safety bars should also be installed in the bathroom to prevent slipping. Vitamin D too can be given; it has been shown to be helpful with people who have dementia (Broe, et al., 2007)
People who have dementia tend to wander as evidenced in Myra's situation. The nurse should warn the family to alert neighbors about the patient's wandering behavior and, for the same reason, alert the police and have the patient's current picture taken. At the same time, however, the nurse should still encourage the patient to keep moving, encouraging physical activity (Ray et al., 2005)
Dementia can be frustrating for the patient. Things that were once familiar are now confused and the patient has to be constantly reminded of her situation and her circumstances. Life becomes scary. To mitigate this overwhelming confusion, Mayo clinic advises that there should be an organized, although flexible schedule in place so that frustrations are reduced, whiles the tasks are performed in a quiet, patient way. Distractions should be eliminated whilst these tasks are performed. Activities too should be familiar to the patient so that, in practical terms, the nurse should confine herself to repeating the same activity various times instead of introducing new ones (such s different entertainment or routine) that would only perplex the patient (WebMD) . To the same end, the nurse should make sure that all clocks, calendars, and familiar personal effects are in the patient's view.
Providing patient-centered care does not mean that the nurse makes the patient dependent on her. On the contrary, the nurse should provide the patient with the skills to enable her to conduct her own life whilst making sure that the patient is protected and receives the necessary social support and care. To that end, the nurse should assess and monitor Myra's ability to perform activities of daily living and she should encourage decision making regarding activities of daily living as much as possible.
To make sure that the patient is well-protected, the nurse not only teaches her family how to care for her but also helps the patient, to the extent that she possibly can, monitor her own health. The nurse herself engages in tasks that include the following: she monitors food and fluid intake; weighs the patient weekly; sit with the patient during meals and assists by cueing.
Moreover, in order to best help Myra, the nurse needs to have knowledge about her illness since dementia can sometimes display the same symptoms like delirium, depression etc.
Last but certainly not least is the importance of simultaneously taking care of her own health and stress level in order to make sure that she herself, as health practitioner, doesn't get sucked into Myra's situation (Samson et al. (2004); Hayslip, et al. (2008)). The nurse should also help the family care for themselves too whilst taking care of the patient. These are just some of the attitudes and practices that are a derivative of client-centered nursing.
Caring for a person with dementia is not easy for anyone. For the nurse, it can sometimes be grueling. Norberg (2012) recommends that the nurse consider that the patient is often in Erickson's last stage of development where the patient looks back and remembers one's life, takes responsibility of the past, realizes that life is about to end, and prepares for death. Some regard their past with contentment; others are dissatisfied and angry. The patient with dementia may be in the latter category in which case she may be all the more difficult a patient.
Dealing with this final stage and achieving wholeness and completion is difficult for any healthy person, but for the person with dementia it is all the more difficult. Working from a client-centered perspective, caregivers of patients with dementia have to remember their pasts for them, see the future form their eyes, and know and respect their philosophy of living. They also have to know how to communicate with them; a task made all the more arduous due to the fact that the patient's mind is apt to wander. In short, the caregiver has to respect his patient as a person who has dignity and respect in her own merit. The patient's condition may rob him of wholeness and familiarity; the nurse should seek to provide this completeness that the patient lacks. This is the crux of patient-centered nursing -- optimum nursing -- that a nurse should practice when caring for a patient such as Myra.
Sansoni, J et al. (2004) Anxiety and depression in community-dwelling, Italian Alzheimer's disease caregivers, retrieved from International Journal of Nursing Practice: 10: 93-100.
Hayslip, B et al. (2008) Predictors of Alzheimer's disease caregiver depression and burden: what noncaregiving adults can learn from active caregivers. Educational Gerontology, 34:…[continue]
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